Improving Indian Health Service hospitals

The Indian Health Service (IHS) is tasked with delivering comprehensive health care
to about 2.2 million Native Americans, but recent evidence has suggested that some
of its hospitals have fallen dangerously short of this goal.

In Rapid City, S.D., for example, the emergency department of Sioux San Hospital was
closed in 2016 for deficiencies so severe that they constituted “an immediate
and serious threat to the health and safety of any individual who comes to your hospital
to receive emergency services,” CMS wrote in a letter to the hospital.

Photo by Thinkstock

Also in 2016, CMS warned the Pine Ridge IHS hospital that it was in “immediate
jeopardy” of closing after CMS inspectors found that staff had failed to appropriately
assess patients, had not adequately factored patient history into diagnoses, had made
patients wait for care they needed immediately, and had been inadequately trained
in intubation and respirator use. The emergency department of a third IHS Great Plains
hospital, Rosebud, was shuttered for seven months after CMS found similar deficiencies.

These cases reveal systemic problems with safety, access, and quality of care at IHS
that extend beyond the Great Plains Area. In Window Rock, Ariz., for example, Crownpoint
Medical Center closed its emergency department, inpatient services, and obstetrics
care units in 2015 due to staffing shortages, according to a press release from the
Navajo Nation.

Today, however, some dedicated clinicians and government initiatives are working to
correct these deficiencies and provide Native Americans with high-quality inpatient
care.

For example, some facilities lack CT scanners, so patients must be flown long distances
to better-equipped IHS medical centers, Dr. Lawrence said. Pregnant patients also
must endure long-distance transfers if their local IHS hospital cannot retain appropriate
obstetric staff. “Particularly challenging to the hospitalists is the lack
of ICUs in many of our facilities, requiring them to make the difficult decision of
admitting or transferring the more critical patients,” Dr. Lawrence added.

Dorothy Sanderson, MD, FACP, agreed. The aging of IHS facilities, infrastructure,
and equipment, combined with geographic isolation and budget shortages, force hospitalists
and their clinical colleagues “to be as creative as possible in finding ways
to provide the culturally sensitive and excellent medical care our patients deserve,”
she said.

IHS hospitals also are uniquely complex, explained Dr. Sanderson, who is a hospitalist
and chief of internal medicine at Phoenix Indian Medical Center in Phoenix. Some are
federal facilities, while others fall under tribal authority. Some have a very limited
scope of practice, while others offer certain specialty and diagnostic services.

But despite—or perhaps because of—these tiered intricacies, IHS headquarters
has for years delegated the oversight of care to its nine geographic areas, according
to a January 2017 report by the U.S. Government Accountability Office (GAO). As a
result, IHS lacked agency-wide standards for quality of care, and oversight of quality
issues was “limited and inconsistent,” the report asserted. For example,
authorities in some IHS areas did not meet regularly and failed to make quality a
standing agenda item at their meetings. Reporting of data on quality and adverse events
also was sporadic and incomplete, the GAO found.

Systemic change

Such revelations spurred IHS in 2016 to craft a quality framework that aspires to
ensure patient safety, boost organizational capacity, and meet and maintain accreditation
standards, the agency stated in a recent press release. IHS also has pledged to expand
existing safety reporting systems and promote a culture of transparency and patient
safety in which hospital staff feel comfortable reporting medical errors.

As part of these efforts, CMS has added IHS to its national Hospital Improvement Innovation
Networks program, which aims to cut overall patient harm by 20% and to reduce 30-day
readmissions by 12% between 2014 and 2019. Premier, Inc., a private health care improvement
company, will serve as the Hospital Improvement Innovation Network organization for
IHS. CMS also has tapped HealthInsight, a nonprofit, community-based organization,
to help coordinate quality improvement efforts at the 25 IHS hospitals that are Medicare-certified.

In the Great Plains Area, a newly hired manager is implementing quality assurance
and performance improvement programs at each of the IHS hospitals, Dr. Lawrence said.
The Great Plains Area also has set new minimum standards for medical equipment and
has contracted with The Joint Commission to provide accreditation, training, and education
on quality assurance and patient safety.

In order to continue receiving CMS reimbursements, the Pine Ridge and Rosebud hospitals
also have agreed to shift executive hospital leadership to expert contractors who
will thoroughly train local administrators and then shift to mentoring and coaching
roles.

The Great Plains Area also has allocated $8.6 million to provide telemedicine services
at all 19 of its service units, which together serve about 130,000 patients. “The
telemedicine initiative is an important step in expanding access to care for patients,
who will receive specialized care nearer to home instead of traveling long distances
to see a specialist,” Dr. Sanderson said.

Local progress

Clinicians at Phoenix Indian Medical Center in Arizona did not await external or top-down
pressure to make positive changes. To support complex patients in the face of limited
resources, surgeons and their colleagues designed a Perioperative Surgical Home (POSH),
a model which the American Society of Anesthesiologists (ASA) promotes as an innovation
for providing safe, patient-centered care.

Perioperative care has become highly fragmented, according to the ASA. The perioperative
surgical home model overcomes this tendency by teaming up hospitalists, surgeons,
anesthesiologists, nurses, pharmacists, respiratory therapists, and nutritionists
so they can comprehensively evaluate medical and psychosocial needs before and after
surgery and create detailed pre- and postoperative needs assessments and treatment
plans, Dr. Sanderson said.

Implementing a POSH enabled Phoenix Indian Medical Center to expand its scope of surgical
services—a vital step for a hospital that serves more than 140,000 patients
from 40 tribes. In addition, evaluations during the early stages of the project revealed
opportunities for improvement, such as a perioperative antibiotic prophylaxis program,
a recovery pathway for colorectal surgery patients, and a ventral hernia program,
which clinicians can tailor based on patient needs, Dr. Sanderson said.

To encourage early mobility after surgery, staff also designed a WeMove! program that
provided detailed instructions for patients, a walking circuit in the medical-surgery
ward, and 55 new chairs. Early results showed patients were out of bed 40% more often
after the program started, Dr. Sanderson said.

Recognizing the need for ongoing staff education, clinicians also designed a web-based
curriculum on the essentials of surgery and began organizing regular lectures at the
hospital for CME credit. To help reinforce the program, they also updated their electronic
health record system to include POSH notes and nursing documentation.

The model is generalizable, Dr. Sanderson emphasized. “Any facility [with]
complex patients requiring multiple encounters in the perioperative setting can benefit
from evaluating the process through which patients prepare for surgical procedures.”

Amy Karon is a freelance writer in San Jose, Calif.

Helping at IHS

Hospitalists and other hospital-based physicians can potentially help Indian Health
Service (IHS) hospitals in several ways, according to IHS physician leaders. They
can share order sets, protocols, and guidelines that have been found to support safe,
high-quality inpatient care at non-IHS hospitals. Some medical centers also have opportunities
for contracting and locum work, which are best investigated by contacting local hospitals
listed online.

For students, trainees, and early-career clinicians, IHS also has partnered with the
National Health Service Corps to expand opportunities for scholarships or loan repayment
in exchange for working in IHS facilities with staffing shortages, said Dorothy Sanderson,
MD, FACP, chief of internal medicine at Phoenix Indian Medical Center in Phoenix.
This program now focuses on clinicians in shortest supply, including physicians, physician
assistants, nurses, pharmacists, dentists, behavioral health providers, and optometrists,
she added.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.